Br. J. Surg. Vol. 66 (1979) 432

Left renal vein ligation in surgery for abdominal aortic aneurysm N. D . F O X A N D R . S. T A Y L O R *

OCCASIONALLY, during surgery on the abdominal aorta, division of the left renal vein is required for technical reasons. In this paper we present 6 patients with abdominal aortic aneurysms in whom the left renal vein was divided but not reconstituted. There were no deaths and all 6, now between 6 months and 3 years after operation, show no significant disturbance of renal function. Patients and methods All 6 patients (4 males and 2 females) had abdominal aortic aneurysms. Four were elective cases, one aneurysm was expanding and required urgent operation and the other was ruptured. In most cases division of the left renal vein was required to obtain safe control of the aorta above the neck o f th e aneurysm or because the vein was densely adherent to the aorta. In one a retro-aortic vein was accidentally torn. In all cases the vein was divided well to the right so as to avoid the left adrenal vein, the most medial tributary. Blood urea estimations were carried out preoperatively on all patients and serum creatinine was measured in 2 of the 4

attributable t o left renal vein ligation. Simon et al. (1972) reported 13 patients in whom the left renal vein or a major tributary was divided to allow end-to-end anastomosis in splenorenal shunts for portal hypertension. There were 5 deaths due to liver disease. None of these patients had any impairment of renal function and the 8 survivors all had normal intravenous pyelograms and renal function tests. Only one example of major damage t o the kidney has been found in a review of the literature; Royster et al. (1974) have reported one patient with a ruptured aneurysm who died several days after operation and in whom post-mortem examination revealed venous infarction of the left kidney following left renal vein ligation.

Conclusion Left renal vein ligation is a safe procedure. There are adequate collateral channels into which venous return from the left kidney can drain, and, provided that the left renal vein is divided far enough to the right to

Table I: DETAILS OF T H E SERIES AND POSTOPERATIVE RENAL FUNCTION TESTS Blood pressure Serum creatinine Age (mm Hg) Blood urea (mmol/l) (mmol/l) PostOD. Preou. Postoo. Case (vrl Sex Oueration Preoo. Postou. Preoo.

T. W. W. M. L. H. T. H. W. T. S. J. N.

42 70 75 72 72 58

M M F

M M F

Elective Urgent Elective Ruptured Elective Elective

150/100

150/100 200/105

80/52 180/95 170/110

140/80 140/80 160/90 110/70 180/100 160/95

elective cases. Postoperative investigations were performed within 6 months of leaving hospital and included blood urea and serum creatinine estimations and a n intravenous pyelogram. It can be seen from Table I that all patients maintained satisfactory renal function and those with blood urea and creatinine levels close to the upper limit of normal have normal intravenous pyelograms. Of particular interest is the observation that all 6 patients have a normal blood pressure.

4.1 13.3 6.2 35.0 5.3 6.2

4.2 8.9 8.2 8.3 4.8 7.0

57

-

64

-

56 181 90 120 80 105

IVP Normal Normal Normal Normal Normal Normal

preserve the adrenal and gonadal veins, no harm should come to the left kidney.

Acknowledgement We wish to thank M r R. M. Greenhaigh, Charing Cross Hospital, for permission t o report 2 of the cases.

References and IYENAGER s. R . K. (1970) Renal function and a technique for venography after left renal vein ligation. Am. J . Surg. 120, 41-45. NEAL H. s. and SHEARBURN E. w. (1967) Division of the left renal vein as an adjunct to resection of abdominal aortic aneurysms. Am. J . Surg. 113, 763-765. ROYSTER T. s., LACEY L. and MARKS R. A. (1974) Abdominal aortic surgery and the left renal vein. Am. J. Surg. 127, 552-554. SIMON I. s., BROWN A. A. and ROSS H. B. (1972) Ligation of the left renal vein in splenorenal anastomosis without impairment of renal function. Br. J. Surg. 59, 170-173. SZILAGYI D. E., SMITH R . F. and ELLIOTT J. P. (1969) Temporary transection of the left renal vein: a technical aid. Surgery 65, 32-40. Paper accepted 8 December 1978.

DE LAURENTIS D. A .

Discussion The major tributaries of the left renal vein are the gonadal veins and the left adrenal vein. The left inferior phrenic vein usually joins the left adrenal vein but may drain directly into the left renal vein. The gonadal vein anastomoses with the lumbar veins and capsular veins drain into the lumbar system. De Laurentis and Iyenager (1970) demonstrated these and other collateral veins draining the kidney after left renal vein ligation using an ingenious radiological technique cannulating a vein in the pampiniform plexus. Szilagyi et al. (1969) reported 20 patients in whom they temporarily divided and reconstituted the left renal vein with no harm to the patients. Neal and Shearburn (1967) reported 11 patients in whom the left renal vein was permanently transected. There were 3 deaths in their series but no death was

* Epsom District Hospital, Epsom, Surrey. Correspondence to: N. D. Fox, The Austin Hospital, Heidelberg, Victoria, Australia.

Left renal vein ligation in surgery for abdominal aortic aneurysm.

Br. J. Surg. Vol. 66 (1979) 432 Left renal vein ligation in surgery for abdominal aortic aneurysm N. D . F O X A N D R . S. T A Y L O R * OCCASIONAL...
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